Association between postinduction hypotension and postoperative mortality: a single-centre retrospective cohort study.

PURPOSE: We aimed to elucidate whether postinduction hypotension (PIH), defined as hypotension between anesthesia induction and skin incision, and intraoperative hypotension (IOH) are associated with postoperative mortality. METHODS: We conducted a retrospective cohort study of adult patients with an ASA Physical Status I-IV who underwent noncardiac and nonobstetric surgery under general anesthesia between 2015 and 2021 at Nagoya City University Hospital. The primary and secondary outcomes were 30-day and 90-day postoperative mortality, respectively. We calculated four hypotensive indices (with time proportion of the area under the threshold being the primary exposure variable) to evaluate the association between hypotension (defined as a mean blood pressure < 65 mm Hg) and mortality using multivariable logistic regression models. We used propensity score matching and RUSBoost (random under-sampling and boosting), a machine-learning model for imbalanced data, for sensitivity analyses. RESULTS: Postinduction hypotension and IOH were observed in 82% and 84% of patients, respectively. The 30-day and 90-day postoperative mortality rates were 0.4% (52/14,210) and 1.0% (138/13,334), respectively. Postinduction hypotension was not associated with 30-day mortality (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 0.93 to 1.13; P = 0.60) and 90-day mortality (aOR, 1.01; 95% CI, 0.94 to 1.07; P = 0.82). Conversely, IOH was associated with 30-day mortality (aOR, 1.19; 95% CI, 1.12 to 1.27; P < 0.001) and 90-day mortality (aOR, 1.12; 95% CI, 1.06 to 1.19; P < 0.001). Sensitivity analyses supported the association of IOH but not PIH with postoperative mortality. CONCLUSION: Despite limitations, including power and residual confounding, postoperative mortality was associated with IOH but not with PIH.

RéSUMé: OBJECTIF: Nous avons cherché à déterminer si l'hypotension post-induction (HPI), définie comme une hypotension entre l'induction de l'anesthésie et l'incision cutanée, et l'hypotension peropératoire (HPO) étaient associées à la mortalité postopératoire. MéTHODE: Nous avons mené une étude de cohorte rétrospective de patient·es adultes ayant un statut physique I-IV selon l'ASA et ayant bénéficié d'une chirurgie non cardiaque et non obstétricale sous anesthésie générale entre 2015 et 2021 à l'Hôpital universitaire de la ville de Nagoya. Les critères d'évaluation principal et secondaire étaient la mortalité postopératoire à 30 et 90 jours, respectivement. Nous avons calculé quatre indices d'hypotension (la proportion temporelle de la zone sous le seuil étant la principale variable d'exposition) pour évaluer l'association entre l'hypotension (définie comme une tension artérielle moyenne < 65 mm Hg) et la mortalité à l'aide de modèles de régression logistique multivariée. Nous avons utilisé l'appariement par score de propension et le RUSBoost (sous-échantillonnage et boosting aléatoire), un modèle d'apprentissage automatique pour les données déséquilibrées, pour les analyses de sensibilité. RéSULTATS: Une HPI et une HPO ont été observées chez 82 % et 84 % des patient·es, respectivement. Les taux de mortalité postopératoire à 30 et 90 jours étaient respectivement de 0,4 % (52/14 210) et de 1,0 % (138/13 334). L'hypotension post-induction n'était pas associée à la mortalité à 30 jours (rapport de cotes ajusté [RCa], 1,03; intervalle de confiance [IC] à 95 %, 0,93 à 1,13; P = 0,60) et à la mortalité à 90 jours (RCa, 1,01; IC 95 %, 0,94 à 1,07; P = 0,82). À l'inverse, l'HPO était associée à une mortalité à 30 jours (RCa, 1,19; IC 95 %, 1,12 à 1,27; P < 0,001) et à la mortalité à 90 jours (RCa, 1,12; IC 95 %, 1,06 à 1,19; P < 0,001). Les analyses de sensibilité ont confirmé l'association de l'HPO, mais pas de l'HPI, avec la mortalité postopératoire. CONCLUSION: Malgré les limitations, y compris la puissance et persistance de facteurs confondants, la mortalité postopératoire était associée à l'hypotension peropératoire mais pas à l'hypotension post-induction seule.

Incidence and factors associated with newly implemented do-not-attempt-resuscitation orders among deteriorating patients after rapid response system activation: A retrospective observational study using a Japanese multicenter database.

Aim: The rapid response system (RRS) was initially aimed to improve patient outcomes. Recently, some studies have implicated that RRS might facilitate do-not-attempt-resuscitation (DNAR) orders among patients, their families, and healthcare providers. This study aimed to examine the incidence and factors independently associated with DNAR orders newly implemented after RRS activation among deteriorating patients. Methods: This observational study assessed patients who required RRS activation between 2012 and 2021 in Japan. We investigated patients' characteristics and the incidence of new DNAR orders after RRS activation. Furthermore, we used multivariable hierarchical logistic regression models to explore independent predictors of new DNAR orders. Results: We identified 7904 patients (median age, 72 years; 59% male) who required RRS activation at 29 facilities. Of the 7066 patients without pre-existing DNAR orders before RRS activation, 394 (5.6%) had new DNAR orders. Multivariable hierarchical logistic regression analyses revealed that new DNAR orders were associated with age category (adjusted odds ratio [aOR], 1.56; 95% confidence interval, 1.12-2.17 [65-74 years old reference to 20-64 years old], aOR, 2.56; 1.92-3.42 [75-89 years old], and aOR, 6.58; 4.17-10.4 [90 years old]), malignancy (aOR, 1.82; 1.42-2.32), postoperative status (aOR, 0.45; 0.30-0.71), and National Early Warning Score 2 (aOR, 1.07; 1.02-1.12 [per 1 score]). Conclusion: The incidence of new DNAR orders was one in 18 patients after RRS activation. The factors associated with new DNAR orders were age, malignancy, postoperative status, and National Early Warning Score 2.

Combined use of the ProSeal laryngeal mask airway and a bronchial blocker vs. a double-lumen endobronchial tube in thoracoscopic surgery: A randomized controlled trial.

STUDY OBJECTIVE: The combined use of the ProSeal laryngeal mask airway and a bronchial blocker may reduce postoperative hoarseness and sore throat. We aimed to test the feasibility and efficacy of this combination technique in thoracoscopic surgery. DESIGN: A single-center, patient-assessor blinded, randomized controlled trial. SETTING: Nagoya City University Hospital (between November 2020 and April 2022). PATIENTS: A total of 100 adult patients undergoing lobectomy or segmentectomy by video- or robotic-assisted thoracoscopic surgery. INTERVENTIONS: Patients were randomly assigned to either group using a combination of the ProSeal laryngeal mask airway and a bronchial blocker (pLMA+BB group) or a double-lumen endobronchial tube (DLT group). MEASUREMENTS: The primary outcome was the hoarseness incidence on 1-3 postoperative days. Secondary outcomes included sore throat, intraoperative complications (hypoxemia, hypercapnia, surgical interruption, malposition of devices, unintended lung expansion, and ventilatory difficulty), lung collapse, device placement-related outcomes, and coughing during emergence. MAIN RESULTS: A total of 100 patients underwent randomization (51 to the pLMA+BB group and 49 to the DLT group). After drop outs, a total of 49 patients in each group were analyzed per-protocol. The incidences of hoarseness in the pLMA+BB and DLT groups were 42.9% and 53.1% (difference, -10.2%; 95% confidence interval, -30.1% to 10.3%; p = 0.419), 18.4% vs. 32.7%, and 20.4% vs. 24.5% on postoperative day 1, 2, and 3, respectively. The incidences of sore throat in the pLMA+BB and DLT groups were 16.3% vs. 34.7% (difference, -18.4%; 95% confidence interval, -35.9% to -0.9%; p = 0.063) on postoperative day 1. In the pLMA+BB group, more intraoperative complications and less coughing during emergence were observed compared to the DLT group. Lung collapse and placement-related outcomes were comparable between the groups. CONCLUSIONS: The combination of ProSeal laryngeal mask airway and bronchial blocker did not significantly reduce hoarseness compared to the double-lumen endobronchial tube.

Anesthetic management of a patient with Freeman-Sheldon syndrome undergoing oral surgery: A case report.

In the anesthetic management in this case was how to manage the patient without causing respiratory depression and respiratory muscle fatigue.

The characteristics, types of intervention, and outcomes of postoperative patients who required rapid response system intervention: a nationwide database analysis.

PURPOSE: Improving the safety of general wards is a key to reducing serious adverse events in the postoperative period. We investigated the characteristics, treatment, and outcomes of postoperative patients managed by a rapid response system (RRS) in Japan to improve postoperative management. METHODS: This retrospective study analyzed cases requiring RRS intervention that were included in the In-Hospital Emergency Registry in Japan. We analyzed data reported by 34 Japanese hospitals between January 2014 and March 2018, mainly focusing on postoperative patients for whom the RRS was activated within 7 days of surgery. Non-postoperative patients, for whom the RRS was activated in all other settings, were used for comparison as necessary. RESULTS: There were 609 (12.7%) postoperative patients among the total patients in the registry. The major criteria were staff concerns (30.2%) and low oxygen saturation (29.7%). Hypotension, tachycardia, and inability to contact physicians were observed as triggers significantly more frequently in postoperative patients when compared with non-postoperative patients. Among RRS activations within 7 days of surgery, 68.9% of activations occurred within postoperative day 3. The ordering of tests (46.8%) and fluid bolus (34.6%) were major interventions that were performed significantly more frequently in postoperative patients when compared with non-postoperative patients. The rate of RRS activations resulting in ICU care was 32.8%. The mortality rate at 1 month was 16.2%. CONCLUSION: Approximately, 70% of the RRS activations occurred within postoperative day 3. Circulatory problems were a more frequent cause of RRS activation in the postoperative group than in the non-postoperative group.

Perioperative management of thyroglossal duct cystectomy in a pediatric patient: A case report.

Thyroglossal duct on the dorsum of the tongue in the pediatric patient can cause a difficult airway due to the large mass and risk of airway obstruction associated with a swollen tongue after surgery.

First report based on the online registry of a Japanese multicenter rapid response system: a descriptive study of 35 institutions in Japan.

AIM: Although the concept of a rapid response system (RRS) has been gradually accepted in Japan, detailed information on the Japanese RRS is not well known. We provide the first report of the RRS epidemiological situation based on 4 years of RRS online registry data. METHODS: This is a prospective observational study. All patients registered between January 2014 and March 2018 were eligible for this study. Data related to RRS including physiological measurements were recorded. The mortality rates after rapid response team/medical emergency team (RRT/MET) intervention and after 30 days were recorded as outcomes. RESULTS: In total, 6,784 cases were registered at 35 facilities. Cancer (23.1%) was the most common existing comorbidity. Limitation of medical treatment was identified in 12.7% of the cases. The respiratory category was most frequently activated in 41.3% of the cases. Only two institutions had received more than 15 calls per 1,000 admissions. During RRT/MET intervention, death occurred in 3.6% and transfers to intensive care units occurred in 28.2% of the cases. After 30 days, the mortality rate was significantly higher in the night than in the day shift (30.7% versus 20.4%, respectively, P < 0.01). CONCLUSIONS: We report the first epidemiological study of RRS in Japan. Japanese facilities had a very low rate of RRT/MET calls and a higher mortality rate in the night than in the day shift. Further promotion to increase the number of calls and implementation of a 24-h RRT/MET is required.

General anesthetic management of a patient with multiple chemical sensitivity for oral surgery: a case report.

BACKGROUND: Multiple chemical sensitivity (MCS) was first described in 1987. It is said that MCS is caused by neurological and immunological mechanisms in addition to psychosomatic mechanisms. When performing general anesthesia in patients with MCS, careful perioperative management is necessary. CASE PRESENTATION: The patient was a 32-year-old man. Wisdom teeth extraction under general anesthesia was scheduled under the diagnosis of pericoronitis. In 2015, he was diagnosed with MCS. Since then, he experienced sweating and urticaria when exposed to artificial fragrances. We prepared the surgical surroundings by letting the patient touch every possible equipment. In selecting the anesthetic drugs, a completely intravenous route was selected because of the possibility that artificial fragrance of inhalation anesthesia could induce symptoms. There was no allergic reaction during the preoperative period. CONCLUSIONS: It is important to reduce psychological burden of patient and to eliminate all possible reactive substances to prevent symptom onset.

Effects of landiolol on refractory tachyarrhythmia after total cavopulmonary connection: a retrospective, observational, cohort study.

The onset of tachyarrhythmia after the Fontan procedure (total cavopulmonary connection; TCPC) should be considered a medical emergency. Landiolol is an ultra-short-acting ß1-selective blocker whose effect on tachyarrhythmia after TCPC is unclear. We evaluated the efficacy and safety of landiolol for tachyarrhythmia after TCPC. Consecutive patients undergoing TCPC were enrolled from January 2007 to December 2011. Of 435 pediatric open heart surgeries, 28 patients underwent TCPC. Of the 28 patients, 13 were treated with landiolol for critical tachyarrhythmia. Excluding three patients who received landiolol during surgery, we investigated the remaining 10 patients and statistical analysis was performed without a 10-year-old patient as outlier. The median age was 4.08 years. The subjects comprised five patients with sinus tachycardia, four with junctional ectopic tachycardia and one with paroxysmal supraventricular tachycardia. The initial dose was 4.7 ± 2.3 µg/kg/min, without a loading dose. Landiolol reduced the heart rate from 151.8 ± 23.2 at the start to 132.9 ± 20.0 at 1 h and 126.1 ± 24.9 at 2 h (P < 0.01 and P < 0.01, respectively), without blood pressure decrease (P = 0.235). Landiolol was effective in treating critical tachyarrhythmia without hemodynamic deterioration. We believe that landiolol is a promising option for postoperative tachyarrhythmia after the Fontan procedure.

[Choice of induction with, or standby of, extracorporeal lung assist (ECLA) in anesthetic management of bronchoscopic yttrium-aluminium-garnet (YAG) laser treatment of airway tumor].

Bronchoscopy with an yttrium-aluminium-garnet (YAG) laser is often used to resect benign and malignant airway tumors and for relief of associated airway stenosis. Complications of this procedure include airway obstruction and hemorrhage. Partial extracorporeal circulation for YAG laser resection in the airway may be helpful in minimizing these complications. Extracorporeal lung assist (ECLA) should be available for such bronchoscopic surgery, although it is not always required. We managed the general anesthesia for bronchoscopic YAG laser resection of airway tumors in two patients. The first case was a 60-year-old man with a right bronchial tumor that had invaded into the trachea across the carina. The narrowest inner diameter of the part of the trachea affected by the lesion was 3 mm. ECLA was initiated for a bronchoscopic YAG laser resection. The second case was a 74-year-old woman with a metastastic lung tumor from osteosarcoma. The narrowest inner diameter of the lesion in the right truncus intermedius was 4 mm. ECLA was kept on standby for possible complications in the bronchoscopic YAG laser resection. These treatments were completed successfully in both patients without any adverse events. ECLA is a useful supporting technique for performing bronchoscopic YAG laser treatment safely ECLA is recommended where a bronchial lesion invades the trachea and crosses the carina, and where a tracheal lesion will not allow passage of a tracheal tube under the bronchoscope. However, ECLA may be kept on standby for a airway tumor limited to one main bronchus, and for a peripheral bronchial lesion, and even for an invasive tracheal lesion through which the tracheal tube under the bronchoscope can pass. Whether it is used or kept on standby depends on the location and severity of airway compromise caused by the airway lesions.